HA- Integumentary PREPU
A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client has a full-time caregiver. The client is consistently incontinent of urine. The client has a surgical diagnosis. The client adheres to a vegetarian diet.
Correct response: The client is consistently incontinent of urine. Explanation: The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for symptoms of stress. recent radiation therapy. pigmentation irregularities. allergies to certain foods.
Correct response: symptoms of stress. Explanation: Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.
The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? "Has anyone in your family ever been diagnosed with skin cancer?" "Have you ever been assessed for diabetes?" "What dietary supplements do you usually take?" "Do you take steroid medications on a regular basis?"
Correct response: "Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.
The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 45-year-old female with 10 year history of cigarette smoking 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years
Correct response: 55-year-old male who lived in California for 20 years Explanation: The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red hair. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.
A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus
Correct response: Cushing's disease Explanation: Hirsuitism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.
Which clinical manifestation should the nurse expect to find in a client with edema? Decreased skin turgor Prominent blood vessels Mottled skin tones Decreased skin mobility
Correct response: Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.
During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? Diabetes mellitus Iron deficiency anemia Vitamin A deficiency Peripheral vascular disease
Correct response: Iron deficiency anemia Explanation: Spoon nails or nails that are thin and concave are associated with iron deficiency, not vitamin A deficiency, peripheral vascular disease, or diabetes mellitus.
Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis
Correct response: Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.
After teaching a group of students about the structure and function of the skin, the instructor determines that the teaching was successful when the students identify which of the following as responsible for variations in skin color? Sebaceous glands Keratin Melanin Eccrine glands
Correct response: Melanin Explanation: Melanin is the brown pigment found in the epidermis that is responsible for pigmentation of the skin. Sebaceous glands secrete an oily substance to lubricate the skin and hair and reduce water loss through the skin. Keratin is a scleroprotein that insoluble in water and renders the skin waterproof. Eccrine glands secrete an odorless colorless fluid, the evaporation of which is vital to the regulation of body temperature
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Nail beds Sclera Palms Oral mucosa
Correct response: Oral mucosa Explanation: Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists it may indicate systemic hypoxemia. Peripheral cyanosis that results from vasoconstriction would most likely be noted in the nailbeds and conjunctival areas.
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? Document the benign findings. Perform a random blood sugar test. Ask the client about a family history of cancer. Refer the client for medical follow-up.
Correct response: Perform a random blood sugar test. Explanation: Linear hyperpigmented areas (Acanthosis nigricans) present in the skin of the neck, axillae, and perianal folds in dark-skinned people suggest diabetes mellitus. A random blood sugar test would provide an objective assessment to identify hyperglycemia. The findings are not indicative of skin cancer, nor are they benign. The client may be referred for medical follow up after additional assessment is completed.
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous cells Sweat glands Subcutaneous tissue Sebum production
Correct response: Sebum production Explanation: Sebum production decreases with age, therefore increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? Vesicle Papule Wheal Cyst
Correct response: Vesicle Explanation: The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.
A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect? Addison disease Vitiligo Tinea versicolor Dermatomyositis
Correct response: Vitiligo Explanation: In vitiligo, depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment is normal skin color; the pale areas are vitiligo. The condition may be hereditary. These changes may be distressing to the patient.
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had chemotherapy. radiation. a recent illness. steroid therapy.
Correct response: a recent illness. Explanation: Beau's lines occur after acute illness and eventually grow out.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. entire skin surface. soles of the feet. adipose tissue.
Correct response: areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.
A patient with a zosteriform rash has a rash that has lesions distributed over a large body area appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion is distributed along a dermatome is distributed equally on both sides of the body
Correct response: is distributed along a dermatome Explanation: A zosteriform rash is distributed along a dermatome.
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border diameter great than 6 cm asymmetry pink color
Correct response: notched border diameter great than 6 cm asymmetry
The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a papule wheal pustule bulla
Correct response: papule
A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by scabies lice ticks allergies
Correct response: scabies Explanation: A serpiginous rash is snaking. This type of rash can be caused by scabies.
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that melanoma skin cancers are the most common type of cancers. African Americans are the least susceptible to skin cancers. usually there are precursor lesions for basal cell carcinomas. squamous cell carcinomas are most common on body sites with heavy sun exposure.
Correct response: squamous cell carcinomas are most common on body sites with heavy sun exposure. Explanation: Squamous cell carcinoma is most common on body sites with very heavy sun exposure.
The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as stage I. stage II. stage III. stage IV.
Correct response: stage II. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.